Figure 200f

Left Panel: the phonocardiogram of a patient with severe valvular pulmonic stenosis as recorded in the second left intercostal space (2 LI CS) and the apex. The long ejection murmur (ESM) has late systole peaking and spills through A2 . There is a marked delay in P2, which is very small in amplitude.
Right panel: at cardiac catheterization, the markedly delayed P2 is shown to be secondary to a large systolic pressure gradient, and its decreased intensity is due to the low pulmonary artery pressure at the time of valve closure. The late peaking of the ejection murmur correlates with the maximum pressure gradient between the right ventricle in pulmonary artery .

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